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GALLSTONES

Gallstones are hardened bits of digestive fluid called bile that can remain dormant for a person's lifetime, or can produce serious life-threatening disease. When bile is needed for the intestines to break down fats, the gallbladder contracts and pushes the bile into a duct that carries it to the small intestine, where it helps with digestion. The gallbladder is filled with bile from where it is produced in the liver. The liver uses products absorbed from the blood to make bile; these products come into the blood from "used" bile from the intestines, thus making a "cycle" of bile production - the enterohepatic circulation. When the cycle is interrupted for some reason, such as a gallstone blocking a bile duct, the system "backs up," and jaundice (yellowing of the skin) and icterus (yellowing of the whites of the eyes) often occurs.  Bile trapped in these ducts can cause inflammation in the gallbladder, the ducts, or, rarely, the liver. If a gallstone should block the bile duct at the place where the pancreas duct joins the bile duct, pancreas enzymes can become trapped in the pancreas and cause an extremely painful inflammation called pancreatitis.  If any of these ducts remain blocked for a significant period of time, severe and possibly fatal infection and damage can occur, affecting the gallbladder, liver, or pancreas. Visible symptoms of a serious problem are fever, yellowing of the eyes and skin, and persistent abdominal pain

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Many risk factors for gallstones have been identified.  Obesity is a major risk factor for the formation of gallstones.  This is felt to derive from the tendency of obese people to have fewer bile salts in bile, increasing the risk of gallstone formation.  Decreased gallbladder emptying is also seen in obese people.  Estrogen, whether from birth control pills, pregnancy, or from hormone replacement therapy can also lead to gallstones by increasing cholesterol levels in bile and decreasing gallbladder emptying.  Native Americans are at ethnic risk of gallstones.  Females are twice as likely as males to have gallstone disease in mid life.  People over sixty years of age are also more likely to have gallstones than others. People on cholesterol lowering drugs are also at increased risk of gallstones due to increased secretion of cholesterol in bile. Diabetics are also at higher risk of having gallstones than other nondiabetics of the same age and gender.  Rapid weight loss and prolonged fasting can also precipitate gallstone formation.

Symptoms of gallstones are often called a gallstone "attack" because they occur suddenly. A typical attack can cause severe sharp pain in the upper abdomen that radiates to the back between the shoulder blades, increases rapidly, and lasts from 30 minutes to several hours. This is also often accompanied by waves of nausea and vomiting. Such symptoms often follow fatty meals.  Danger signs of a life-threatening gallbladder attack can include severe, unremitting pain, sweating, chills, fever, jaundice, or whitish stools. These can indicate blockage of a bile duct or gallblabber with development of possible infection, and require emergency attention.  Of course, with any question regarding your health, you should consult your doctor or other health care professional right away.

Many tests are available to help with the diagnosis of gallbladder and gallstone disease. In a cholecystogram or cholescintigraphy, the patient is injected with a special iodine dye, and x-rays are taken of the gallbladder over a period of time. (Some people swallow iodine pills the night before the x-ray.) The test shows the movement of the gallbladder and any obstruction of the cystic duct. In endoscopic retrograde cholangiopancreatography (ERCP), the patient swallows an endoscope—a long, flexible, lighted tube connected to a computer and TV monitor. The doctor guides the endoscope through the stomach and into the small intestine. The doctor then injects a special dye that temporarily stains the ducts in the biliary system. ERCP is used to locate stones in the gallbladder and bile ducts, and in many cases can be used to remove small to moderate sized stones from the bile duct system. Blood tests may be used to look for signs of infection, obstruction, pancreatitis, or jaundice.

How are gallstone diseases treated?

Surgery to remove the gallbladder is the most common way to treat symptomatic gallstones. (Asymptomatic gallstones usually do not need treatment.) Each year more than 500,000 Americans have gallbladder surgery. The surgery is called cholecystectomy.  The standard surgery is called laparoscopic cholecystectomy. For this operation, the surgeon makes several tiny incisions in the abdomen and inserts surgical instruments and a miniature video camera into the abdomen. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon a closeup view of the organs and tissues. While watching the monitor, the surgeon uses the instruments to carefully separate the gallbladder from the liver, ducts, and other structures. Then the cystic duct is cut and the gallbladder removed through one of the small incisions.  Because the abdominal muscles are not cut during laparoscopic surgery, patients have less pain and fewer complications than they would have had after surgery using a large incision across the abdomen. Recovery usually involves only one night in the hospital, followed by several days of restricted activity at home.

If the surgeon discovers any obstacles to the laparoscopic procedure, such as infection or scarring from other operations, the operating team may have to switch to open surgery. In some cases the obstacles are known before surgery, and an open surgery is planned. It is called "open" surgery because the surgeon has to make a 5- to 8-inch incision in the abdomen to remove the gallbladder. This is a major surgery and may require about a 2- to 7-day stay in the hospital and several more weeks at home to recover. Open surgery is required in about 5 percent of gallbladder operations.The most common complication in gallbladder surgery is injury to the bile ducts. An injured common bile duct can leak bile and cause a painful and potentially dangerous infection. Mild injuries can sometimes be treated nonsurgically. Major injury, however, is more serious and requires additional surgery.

If gallstones are in the bile ducts, the surgeon may use ERCP in removing them before or during the gallbladder surgery. Once the endoscope is in the small intestine, the surgeon locates the affected bile duct. An instrument on the endoscope is used to cut the duct, and the stone is captured in a tiny basket and removed with the endoscope. This two-step procedure is called ERCP with endoscopic sphincterotomy.  Occasionally, a person who has had a cholecystectomy is diagnosed with a gallstone in the bile ducts weeks, months, or even years after the surgery. The two-step ERCP procedure is usually successful in removing the stone.

Fortunately, the gallbladder is an organ that people can live without. Losing it won't even require a change in diet. Once the gallbladder is removed, bile flows out of the liver through the hepatic ducts into the common bile duct and goes directly into the small intestine, instead of being stored in the gallbladder. However, because the bile isn't stored in the gallbladder, it flows into the small intestine more frequently, causing diarrhea in some people. Also, some studies suggest that removing the gallbladder may cause higher blood cholesterol levels, so occasional cholesterol tests may be necessary.